Antithrombotic Therapy for Secondary Stroke Prevention in Patients With Symptomatic Large-Artery Atherosclerosis and Atrial Fibrillation: A Multicenter Experience.
Mohamed G, de Havenon A, et al. • Journal of the American Heart Association • 2026
In patients with atrial fibrillation and symptomatic large-artery atherosclerosis, recurrent ischemic events and mortality were common and antithrombotic management varied substantially; single anticoagulant+sAP was associated with lower observed short-term stroke/death than single anticoagulant, but bleeding remains a concern with prolonged therapy, and prospective studies are needed.
Key Findings
Results
Single anticoagulant plus single antiplatelet was the most common discharge regimen in this multicenter cohort, while triple therapy was uncommon.
Retrospective analysis of 191 consecutive patients with atrial fibrillation and ischemic stroke related to symptomatic large-artery atherosclerosis at 4 US comprehensive stroke centers.
Median age was 75 years (IQR, 68-83); 40% were women; 36% had prior stroke/TIA.
Single anticoagulant+sAP was used in 33%, single anticoagulant in 25%, and triple therapy (single anticoagulant+dual antiplatelet therapy) in 4%.
Results
More than half of patients switched antithrombotic regimens within 1 year, mostly because a planned duration ended.
Switches occurred mostly as the planned duration ended (71%).
12% of switches followed an outcome event.
Authors conclude that antithrombotic management varied substantially.
Results
Recurrent ischemic stroke and symptomatic hemorrhage were common during follow-up, with over half of each occurring within 90 days.
Median follow-up was 68 days (IQR, 28-120).
21 patients (11%) had recurrent ischemic stroke.
26 patients (14%) had symptomatic hemorrhage.
25% of deaths occurred within 90 days.
Results
At 90 days, stroke/death was higher with single anticoagulant than with single anticoagulant+sAP, while symptomatic hemorrhage showed the opposite pattern.
Ninety-day stroke/death rate was 24% with single anticoagulant versus 8% with single anticoagulant+sAP.
Symptomatic hemorrhage rate was 0% with single anticoagulant and 12% with single anticoagulant+sAP.
Overall 90-day stroke/death rate was reported as 24% in the abstract's comparison with single anticoagulant.
Results
At 1 year, stroke/death rates differed across regimens, being highest with single antiplatelet therapy and lowest with dual antiplatelet therapy.
Stroke/death was 27.3% with sAP, 11.1% with single anticoagulant+sAP, 4.5% with single anticoagulant, and 0% with dual antiplatelet therapy.
Symptomatic hemorrhage was similar across groups at 1 year.
Conclusions
The authors conclude that single anticoagulant+sAP was associated with lower observed short-term stroke/death than single anticoagulant, but bleeding remains a concern with prolonged therapy.
The study was a descriptive, retrospective analysis of real-world prescribing patterns and outcomes.
Outcomes were recurrent ischemic stroke, symptomatic hemorrhage, and death at 90 days and 1 year.
Authors state that prospective studies are needed to define the optimal regimen and duration for this high-risk population.
What This Means
This study looked at people who had a stroke caused by hardened, narrowed arteries (large-artery atherosclerosis) and who also had atrial fibrillation, an irregular heartbeat that raises stroke risk. It's unclear what blood-thinning treatment is best for this group, because the two conditions call for different drugs: anticoagulants for the heart rhythm problem and antiplatelet drugs for artery disease. Researchers reviewed records of 191 patients at 4 US stroke centers to see which treatments doctors actually used and what happened afterward.
Doctors used many different approaches. The most common was an anticoagulant plus one antiplatelet drug (33%), followed by an anticoagulant alone (25%). More than half of patients had their regimen changed within a year, usually because a planned treatment period ended. Bad outcomes were common: about 11% had another ischemic stroke and 14% had serious bleeding, many within the first 90 days. In the first 90 days, stroke or death was more frequent among those on an anticoagulant alone (24%) than among those on an anticoagulant plus an antiplatelet (8%), but serious bleeding occurred only in the combination group (12% vs 0%).
This research suggests that this patient group faces high risks of both repeat stroke and bleeding, and that combining drugs may lower short-term stroke or death while raising bleeding concerns, especially with longer use. Because the study was retrospective, had small subgroups, and was not a randomized comparison, it cannot show which treatment is best. The authors call for prospective studies to determine the best regimen and how long it should be used.
Mohamed G, de Havenon A, Martin R, Nahab F, Kasshout T, Qdais A, et al.. (2026). Antithrombotic Therapy for Secondary Stroke Prevention in Patients With Symptomatic Large-Artery Atherosclerosis and Atrial Fibrillation: A Multicenter Experience.. Journal of the American Heart Association. https://doi.org/10.1161/JAHA.126.050008